Diabetes Prevention Program Pre-screening and Risk Assessment Survey

Demographics

Question Title

* Address

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

Question Title

* What is your date of birth?

Date / Time

Date

Question Title

* What is your age?

18 to 24

25 to 34

35 to 44

45 to 54

55 to 64

65 to 74

75 or older

Question Title

* What is your ethnicity? (Please select all that apply.)

American Indian or Alaskan Native

Asian or Pacific Islander

Black or African American

Hispanic or Latino

White / Caucasian

Prefer not to answer

Other (please specify)

Question Title

* What is your gender?

Female

Male

Question Title

* Which of the following best describes your current relationship status?

Married

Widowed

Divorced

Separated

In a domestic partnership or civil union

Single, but cohabiting with a significant other

Single, never married

Question Title

* What is the highest level of education you have completed?

Question Title

* Your total household income is between:

Less than to $10,000

$10,001 to $25,000

$25,001 to $50,000

$50,001 to $100,000

$100,001 to $200,000

$200,001 or over

Question Title

* Do you participate in SNAP?

Yes

Question Title

* Are you on Medicaid?

Yes